From the Research
DVT prophylaxis for ESRD patients should be approached with caution due to their altered pharmacokinetics and increased bleeding risk, and low-dose unfractionated heparin (UFH) 5000 units subcutaneously twice or three times daily is generally preferred over low molecular weight heparins (LMWHs) as supported by the most recent study 1. For hospitalized ESRD patients requiring DVT prophylaxis, the following options can be considered:
- Low-dose UFH 5000 units subcutaneously twice or three times daily
- If LMWHs are used, enoxaparin should be dose-reduced to 30 mg once daily, as shown in a study comparing enoxaparin and UFH in ESRD patients on hemodialysis 1
- Mechanical prophylaxis with intermittent pneumatic compression devices or graduated compression stockings should be considered for patients with high bleeding risk Some key points to consider when implementing DVT prophylaxis in ESRD patients include:
- Impaired renal clearance of many anticoagulants, which can lead to drug accumulation and increased bleeding complications
- Platelet dysfunction and other hemostatic abnormalities that further increase bleeding risk, as noted in a study on the safety and efficacy of enoxaparin in hemodialysis patients 2
- The need for careful risk-benefit assessment when implementing DVT prophylaxis, taking into account the individual patient's risk factors and medical history It's also important to note that routine DVT prophylaxis is not recommended for outpatient hemodialysis patients unless additional risk factors are present, and that warfarin with careful INR monitoring is often used when anticoagulation is needed for other indications in ESRD patients, though direct oral anticoagulants (DOACs) like apixaban may be considered at reduced doses in select patients, as discussed in a study on the efficacy and safety of enoxaparin during hemodialysis 3.